November 10-15

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ACR Convergence 2023

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Skin disorders can provide window into diagnosis


3 minutes

An ARHP session this afternoon will help practitioners recognize how the skin can serve as an early warning system for rheumatological diseases.

Co-presenters David Rosmarin, MD, Assistant Professor of Dermatology at Tufts University School of Medicine, and Michael K. Lichtman, MD, Assistant Professor of Dermatology and Peter E. Pochi Junior Chair of Research at Boston University School of Medicine, will help practitioners recognize the cutaneous manifestations of inflammatory disorders. During Update: Skin Features of Rheumatological Diseases from 2:30 – 4:00 pm today in room 204A, Dr. Rosmarin will focus mainly on psoriasis and dermatomyositis.

“A lot of these autoimmune diseases manifest via the skin. and the skin is a window into what is happening internally,” Dr. Rosmarin said. “It can be very helpful with the diagnosis of these conditions.”

Along with Gottron’s papules, shawl sign, mechanic’s hands, and heliotrope rash — classic symptoms of dermatomyositis — Dr. Rosmarin said there is a newly characterized feature. An ovoid palatal patch is highly associated with the presence of anti-TIF1 antibodies. This sign may be associated with a higher risk of malignancy. Another advance, he said, is the emergence anti-MDA5 positive dermatomyositis. This is associated with interstitial lung disease and portends a poor prognosis.

Dr. Rosmarin said that nail disease is commonly associated with psoriatic arthritis. Pustular psoriasis is associated with abnormalities in IL-36 receptor antagonist signaling. In addition to acitretin, ustekinumab is effective against pustular psoriasis.

During his part of the session, Dr. Lichtman will tackle lupus and scleroderma.

“When we talk about the skin findings for lupus, one way of differentiating them are those that are associated with systemic findings and those that are not,” he said. “The other way in dermatology that we sort it out is between acute, subacute, and chronic cutaneous lupus.”

Systemic lupus erythematosus (SLE) is the one most people are familiar with, Dr. Lichtman said. SLE may have skin findings, but the skin findings of lupus can exist without SLE. The classic acute cutaneous manifestation of lupus is the malar rash, the butterfly-shaped rash across the cheeks and nose, which is typically associated with SLE.

The subacute form is associated with SLE about half the time, he said, and can mimic diseases such as psoriasis. Chronic lupus is usually not associated with SLE. The most common type of chronic cutaneous lupus is discoid lupus.

Discoid lesions are rarely found below the chin, occurring most often on the scalp and outer ear, and are usually slightly elevated red or pink areas that form flakes or a crust on the surface of the skin. The center area will become depressed and scar over time as these lesions mature. They may be itchy and get larger, spreading outward and then leaving a central scar.

Dr. Lichtman’s research focuses on finger ulcers related to the most pernicious form of scleroderma, systemic sclerosis. That symptom affects as many as half of the people with systemic sclerosis, he said, and he will briefly discuss his work into identifying medications that may prevent the development of finger ulcers.

“Unfortunately, people with systemic sclerosis develop hardening of their skin, starting with their fingers and hands, and in turn, because of poor blood supply and the inability of the tissue to move, they are prone to developing breakdowns of the skin that can ulcerate and lead to gangrene and loss of fingers as well,” he said.

Update: Skin Features of Rheumatological Diseases
2:30 – 4:00 pm Today • Room 204A